May I Have Your Attention, Please?

"We have the results of your HIV test," the attending physician had begun. But fate interrupted with a seemingly endless loudspeaker announcement:

"May I have your attention, please? Would the following patients please report to the nurse's station for morning medications...."

Nothing about Benjamin's story was ordinary. He had been voluntarily admitted to an inpatient psychiatry unit after reporting many symptoms of depression--extreme somnolence, fatigue, thirty-pound weight loss with poor appetite, diffuse pain, decreased energy and joylessness for about three months.

Benjamin was charming, smart and eager to follow medical advice. As a relatively inexperienced medical student, I found interviewing him a refreshing change of pace from my difficult interactions with the poorly groomed individuals who paced the halls repeating nonsensical phrases and questions over and over again. Benjamin always peppered our talks with comments about current events and informed questions about his care. He could often be seen reading the newspaper or interacting with other patients or staff in a way that made me wonder whether he really belonged there.

Benjamin's life story was as engaging as his demeanor. He had worked as a city fire fighter for about thirty years before injuring his leg on the job--an injury that brought him chronic pain and an early retirement.

More dramatically, after twenty years of marriage Benjamin had come out as a gay man. He'd then proceeded to engage in unprotected sex with multiple partners.

With so many physical complaints, including weight loss and low energy, we had to wonder whether some of his symptoms, including the depression itself, might be manifestations of HIV infection. But I was reassured when he told me that he had tested negative just two months prior. We performed the test anyway, knowing that it would be days before we'd get the results, and continued treating him as a simple case of depression.

Over the next week, Benjamin responded well to antidepressants, and one day the entire treatment team agreed that he was ready for discharge the following morning. We informed him and prepared his paperwork. That evening I checked the computer for any new lab results. The screen read, "HIV antibody test: Positive, confirmed with Western Blot."

This must be a mistake, I thought. Then feelings of despair and disappointment crept over me.

The news felt like a punch in the stomach; it was also a logistical nightmare. My attending physician suggested I inform the patient that we'd need to do some more tests before his discharge (to figure out how advanced his HIV was). We would tell him his diagnosis in the morning.

Excuse me? So, as the least experienced person on the team, I'm supposed to tell the patient that he won't be discharged as planned and that we need more blood tests, without giving him any hint about his new diagnosis or what the blood tests are for?

Noting my obvious distress, my supervising resident joined me on the long journey to the patient's room and took the lead in discussing the situation with him. Very casually, he mentioned that we would need to do a few more tests before he could be discharged; Benjamin nodded stoically.

"I understand," he said knowingly.

The next morning, with the team gathered, the patient walked down the corridor to the "music room" at a snail's pace. He looked like someone on his way to the electric chair. I wondered if on some level he knew about the news he was about to receive. Were his slow steps an attempt to hold onto his happy innocence as long as possible? As for me, I found myself walking faster than usual despite my best efforts to seem casual.

When everyone had finally gathered, the attending began his well-rehearsed talk. When he arrived at the punchline and the loudspeaker interrupted him, I couldn't bear to make eye contact with anyone--not the attending, holding up a finger to signal patience, and not Benjamin, who seemed to be handling the situation far more gracefully than I.

The announcement lasted for what felt like the longest fifteen seconds of my life, then the attending resumed:

"The test came back positive."

Benjamin closed his eyes and sat perfectly still. I waited for any kind of emotional reaction, but none came. What followed was a very ordinary conversation about what these results meant and how they would affect his life. Benjamin, staring at the floor, said that he wished he'd been more careful and added that perhaps he hadn't been tested in recent months as he'd thought. He thanked us and finally smiled in my direction as if to tell me that everything would be all right.

I felt myself exhale.

My experience with Benjamin taught me that in medicine, roles can get blurred and near-certainties turned upside-down in moments. I now have a better sense of why doctors so often distance themselves emotionally from their patients' outcomes; the alternative is to feel the awful hurt that I felt when I came face-to-face with Benjamin's diagnosis.

Yet I'm glad that I got to know Benjamin, talked openly with him--and cared enough to ache. I will carry that experience with me for the rest of my career.

About the author:

Adam Philip Stern, a fourth-year medical student at SUNY Upstate Medical University, is interested in psychiatry. Prior to medical school, he attended Brown University. "I have written creatively for as long as I can remember and hope that writing will make me a better doctor even as medicine makes me a better writer." Adam's novella The Insatiable Manis available through online booksellers and his fiction has been published in The Healing Muse, Lifelines, Harmony Magazine, Blood and Thunder and The Rejected Quarterly. The latest information about Adam's writing can be found at his website www.AdamPhilipStern.com.